D.C. Mun. Regs. tit. 29, r. 29-991

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-991 - OTHER LABORATORY AND X-RAY SERVICES

991.1

Medicaid reimbursable other laboratory and x-ray services shall be professional and technical laboratory and radiological services that are:

(a) Medically necessary;

(b) Ordered, in writing, by a physician or advanced practice registered nurse (APRN) who is screened and enrolled as a District Medicaid program provider pursuant to 29 DCMR §§ 9400et seq.; and

(c) Provided in an office or similar facility other than a hospital outpatient department or clinic.

991.2

All ordering clinicians shall be licensed pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1202et seq.)

991.3

Coverage of and Medicaid reimbursement for other laboratory and x-ray services shall be limited as follows:

(a) Other laboratory and x-ray services performed in connection with a routine physical examination shall not be billed separately;

(b) Services primarily for, or in connection with, cosmetic purposes shall require prior approval by the Department of Health Care Finance or its designee;

(c) Services primarily for, or in connection with, dental or oral surgery services, shall be limited to those required as a result of the emergency repair or accidental injury to the jaw or related structure; and

(d) Other laboratory and x-ray services provided to an individual who is in an outpatient setting, including services referred to an outside office or facility shall be included in a hospital outpatient claim.

991.4

To receive Medicaid reimbursement, a provider of other laboratory services shall meet the following requirements:

(a) Be certified under Title XVIII of the Social Security Act and the Clinical Laboratories Improvement Amendments of 1988;

(b) Be licensed or registered in accordance with D.C. Official Code § 44-202;

(c) Hold an approved District Medicaid program Provider Agreement as an independent laboratory provider; and

(d) Be screened and enrolled as a District Medicaid provider pursuant to 29 DCMR § 9400.

991.5

To receive Medicaid reimbursement, a provider of x-ray services shall be:

(a) Licensed or registered in accordance with D.C. Official Code § 44-202 and other applicable District of Columbia laws;

(b) In compliance with manufacturer's guidelines for use and routine inspection of equipment; and

(c) Screened and enrolled as a District Medicaid provider pursuant to 29 DCMR § 9400.

991.6

Medicaid reimbursement rates for other laboratory or x-ray services shall be eighty percent (80%) of the rates established by Medicare, and will not exceed Medicare on a per test basis.

991.7

The Department of Health Care Finance shall publish Medicaid reimbursement rates for other laboratory or x-ray services on the District Medicaid fee schedule, available online at www.dc-medicaid.com.

991.99

DEFINITIONS

For purposes of this section, the following terms shall have the meanings ascribed.

Outpatient - A patient of an organized medical facility, or distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a twenty-four (24) hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight in accordance with the requirements set forth in 42 C.F.R. § 440.2.

Professional service - A service that may only be provided by a physician or Advanced Practice Registered Nurse who is qualified to analyze a procedure or service and providing a written report of findings.

Technical services - Services necessary to secure a specimen and prepare it for analysis, or to take an x-ray and prepare it for reading and interpretation, e.g., machines test, laboratory, and radiology procedures.

D.C. Mun. Regs. tit. 29, r. 29-991

Final Rulemaking published at 62 DCR 15314 (11/27/2015)